Know how to code and bill for nutritional counseling
By David Klein, CPC, CHC
When determining how to code and bill for nutritional counseling services, you must assess whether the patient is presenting with actual symptoms, an established illness that requires nutritional counseling, or whether the patient requires preventive services.
If you bill based on coverage or payment rather than medical necessity, you are at risk of post-payment recovery to the carrier where it can be shown that the billing — and the resulting separate payment — was not justified by the documentation or circumstances of treatment.
The following are some guidelines for proper billing.
Patients presenting without an illness or injury
Most nutritional counseling services are preventive in nature. So, how should you code for nutritional counseling when a patient presents with no underlying condition?
Look to the “Preventive Medicine, Individual Counseling E/M” codes, CPT 99401–99412. These codes are used to report counseling services provided to individuals at a separate encounter for the purpose of promoting health and preventing illness or injury.
“Preventive medicine counseling and risk factor reduction interventions provided as a separate encounter will vary with age and should address such issues as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter.”1
In most cases, these services will not be covered and therefore the patient should be notified of the likelihood for out-of-pocket costs.
Patients presenting with an illness or injury
How should you bill for this service when medically necessary? Oftentimes, doctors code for nutritional counseling services based on the medical nutrition therapy (MNT) codes 97802-97804.
However, according to CPT this is not the correct way to bill for these services.
“Specially trained physicians may occasionally provide nutrition services. In such cases, evaluation and management or preventive medicine service codes are used to report the service.”2
Instead, bill for nutritional counseling using the “Evaluation and Management” service codes.
For example: Office or other outpatient visit 99201-99215. In such instances, this type of service is typically considered a “counseling” component to the overall E/M service chosen.
Counseling includes the following components:
- Diagnostic results, impressions, and/or recommended diagnostic studies;
- Risks and benefits of management (treatment) options;
- Instructions for management (treatment) and/or follow-up;
- Importance of compliance with chosen management (treatment) options;
- Risk factor reduction; and
- Patient and family education.
“When these activities and/or coordination of care constitute more than 50 percent of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) time may be considered the key or controlling factor to qualify for a particular level of E/M service.”3
As stated above, if counseling and/or coordination of care constitute more than 50 percent of the visit, then the level of E/M is selected based on the total face-to-face physician/patient time and can result in a higher level of E/M service.
You must include a record of total time of the visit as well as the time spent and the specific counseling or coordination of care activities. The note should also include a description of the type and content of the counseling that occurred.
Remember, when CMT (98940-98943) is billed with E/M (99201-99215) services, make sure you append modifier -25 to the E/M service.
Choosing the correct diagnosis
When choosing the correct diagnosis for a patient who presents with actual symptoms and/or an established illness that requires nutritional counseling, look at the chief complaint(s), and contributing condition(s) that support the rationale behind counseling the patient.
Typically, patients who fall into this category would, in addition to their chief complaint/medically necessary diagnosis, also have a contributing condition such as obesity or diabetes.
However, if a patient is presenting to your office with no particular complaint and/or wants preventive services, consider using “V” codes. V codes are diagnosis codes defined as “Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01-V85).” This classification of codes is provided for situations other than a disease or injury.
For example: Dietary surveillance and counseling (V65.3) may be appropriate for patients who present without symptoms or established illness.
The steps to properly bill and code for nutritional counseling in your practice should always be based on patient needs and proper coding rules. Coverage should never determine how a provider should bill for services provided to the patient.
Will carriers pay for the preventive medicine codes? Medicare does not pay for these services and most carriers follow Medicare’s lead.
Certain policies may have provisions that allow preventive medicine services to be paid. However, the majority of the time, patients will be directly responsible for payment.
David Klein, CPC, CHC, is the co-founder of PayDC, a Web-based Electronic Health Records system. He is a certified professional coder and is certified in healthcare compliance. He can be reached at firstname.lastname@example.org or through www.paydc.com.
1 American Medical Association. “Coding for Counseling.” CPT Assistant. January 1998, Vol. 8, Issue 01, p. 5.
2 American Medical Association. “Medical Nutrition Therapy.” CPT Assistant. November 2003, Vol. 13, Issue 11, p. 1.
3 American Medical Association. “Counseling and/or Coordination of Care.” CPT Assistant. August 2004, Vol. 14, Issue 08, p. 1.